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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t �y f(For Non-Transferable, Revocable, and Suspendable) <br /> [J{il 1'/ ENVIRONMENTAL'HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) -b A WAR- Address PO B-OX /5VS-0 .Sr-Oce rvAl 9a'Lo/ <br /> z Owner /j?A AsA�R X5,4 Address <br /> u Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. !o&--9?6x17 Emergency Telephone No. <br /> Contractor Licence No. 24 3�3 <br /> Applicants Name (Print) /Ci-7}/P� GlJ00-rpTitle 25 r-/ Date 8-�-79 <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites l.U_ <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No _ CAL Liczn3e Renewal No. <br /> Capacity Gal., Weights &Measures No .. A <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored _ s <br /> No. of Chemical Toilets Stored ' <br /> 3. ❑ PERCOLATION TEST 3 <br /> R.S. or R.C.E. Name R.S. or-R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ,0 SANITATION PERMIT <br /> Job Address/Location TS-'e-3 7-ZJ.✓ <br /> Owner O AR-L,C-if W 150 ti9D Address,"44S`--3 B A L S..p.sa' `-S T T©-A/ 64 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE*PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW G X"REPAIR {;a - "❑ OTHER .' J <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June-30�19 <br /> Type Construction 'Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) "4 <br /> 6. 11 PACKAGE TREATMENT PLANT For July'1, -June 30, 19 !- - <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity - t --t No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,-19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ Moe Than-1,000 Sq`. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.,"7- <br /> F <br /> I hereby certify that I have prepared this application and that the work will be,done in accordance.with San'Joaquin.County <br /> ordinances, state laws, and rules and regulation an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r — <br /> ` a <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑,EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT. <br /> BASE EXPLANATION BILLING REMITTANCE $ i AMOUNT DUE CHECKED <br /> --T <br /> —DATE—-- DATE DATE-------- REMITTED ,ter AMOUNT <br /> FEE O '( <br /> LESS <br /> PRORATION <br /> PLUS 7 <br /> PENALTY <br /> OTHER 1 <br /> OTHER Vis.. -�^"" . f <br /> 42 <br /> Rec d by ate Receipt No. Permit o. Issuance Dat Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -:1601 E..HAZELTON AVE.,P.O:Box 2009 STOCK,.ON,CA 5201 j <br />